Chapter 65--Multisystem Failure
MULTIPLE CHOICE
1. The nurse is caring for a client who has sustained multiple injuries from a motor vehicle accident.
... [Show More] The
nurse realizes that the client will have a release of stress hormones that are useful for all of the
following EXCEPT:
1. preventing loss of fluids.
2. preventing hypotension.
3. preventing infection.
4. preventing ingestion of food.
ANS: 4
The purpose of the release of stress hormones following an insult to the body is to aid in restoring
balance to the system and to prevent secondary complications, including loss of fluids, hypotension,
and infection. The stress hormones are not released to prevent the ingestion of food.
PTS: 1 DIF: Analyze REF: Neuroendocrine System Response
2. The nurse is planning care for a client diagnosed with acute respiratory distress syndrome (ARDS)?
Which of the following is not included in the management of this disorder?
1. Treating the underlying cause
2. Promoting gas exchange
3. Providing oxygen therapyPromoting urine output
ANS: 4
The nursing management of ARDS includes facilitating oxygenation and ventilation, which is
accomplished by treating the underlying cause, promoting gas exchange, and providing oxygen
therapy. Promoting urine output is not part of the management of this disorder.
PTS: 1 DIF: Apply
REF: Acute Respiratory Distress Syndrome: Planning and Implementation
3. The nurse, caring for a client diagnosed with shock, realizes that the stage in which the body attempts
to remedy the problem by initiating the homeostatic mechanism would be?
1. Initial stage
2. Compensatory stage
3. Multiple organ failure stage
4. Refractory stage
ANS: 2
During the compensatory stage, the body tries to remedy the problem. If it cannot, cellular damage will
occur and organ failure and death may follow. During the initial stage, there is a decrease in cardiac
output and impaired tissue perfusion. In multiple organ failure, every system in the body is affected. In
the refractory stage, the body can no longer respond to therapy and the shock condition is considered
irreversible.
PTS: 1 DIF: Analyze REF: The Four Stages of the Shock Syndrome
4. A client experiences a bee sting, complains of difficulty breathing, and shows sign of hypoxia and
hypotension. The nurse realizes these are signs of anaphylactic shock, and she should do which of the
following first?1. Get a medical alert bracelet for the patient.
2. Give epinephrine intravenously or via endotracheal tube.
3. Check with the family for a history.
4. Admit the client through the admitting department.
ANS: 2
Anaphylactic shock is a medical emergency, and treatment is needed immediately. The nurse should
expect to give epinephrine to promote bronchodilation and vasoconstriction. The other choices can be
done after the client’s airway and ventilation are stabilized.
PTS: 1 DIF: Apply REF: Anaphylactic Shock: Pharmacology
5. A client is diagnosed with failure of the left ventricle to provide adequate delivery of oxygen to the
body tissues due to a weakened forward pumping function of the heart. The nurse realizes this client is
experiencing:
1. anaphylactic reaction.
2. cardiogenic shock.
3. hypovolemia.
4. metabolic acidosis.
ANS: 2
In cardiogenic shock, there is an impaired forward pumping function with decreased stroke volume
and decreased cardiac output. This dysfunction results in a backup of blood into the pulmonary system,
and it can cause metabolic acidosis. Anaphylactic shock is a systemic reaction to an antigen.
Hypovolemia is a loss of circulating blood. Metabolic acidosis is an acid-base imbalance that can
occur from a variety of health conditions or disease processes.
PTS: 1 DIF: Analyze REF: Cardiogenic Shock
6. To assess if the renal system in a client diagnosed with multisystem failure is functioning properly, the
nurse would expect to see urine output of:
1. 10 mL per hour.
2. 20 mL per hour.
3. 30 mL per hour.
4. 40 mL per hour.
ANS: 3
Elimination of 30 mL per hour of urine is considered to be an approximate estimate of renal function.
A urine output less than 30 mL per hour indicates renal failure. A urine output of greater than 40 mL
per hour is considered within normal limits.
PTS: 1 DIF: Apply
REF: Box 65-6 Selected Manifestations of Cardiogenic Shock
7. The nurse realizes that a client, diagnosed with neurogenic shock, is at risk for developing:
1. skin breakdown.
2. sweating.
3. deep vein thrombosis.
4. infection.
ANS: 3
The client is at a greater risk for deep vein thrombosis (DVT) because of the pooling of blood in the
lower extremities. The client is at risk for skin breakdown, sweating, and infection; however, the risk
for a DVT is a priority during the shock phase.PTS: 1 DIF: Analyze REF: Neurogenic Shock: Pathophysiology
8. A client is diagnosed with septic shock. The nurse realizes that the major cause of this type of shock is: [Show Less]